I recently wrote an article on Enterprise Imaging for Radiology Business Journal.  While I cannot reprint that article here, you can access it using this URL link to the Journal’s e-publication. The article reinforces the concept of broadening the scope of enterprise imaging beyond consideration of the traditional, DICOM-oriented departmental PACS to include images produced during such procedures as surgery, endoscopy, ophthalmology, and numerous other “oscopies” and “ologies” from bronchoscopy to urology.  It also emphasizes the need to include non-DICOM as well as DICOM images, still-frame images as well as video clips, image sets that are the result of ordered procedures, as well as image sets that are simply captured on mobile devices during office visits or encounters in departments such as dermatology and emergency.

Organizations planning on replacing a PACS, deploying a VNA, or image-enabling their EMR with a universal viewer really should develop their Enterprise Imaging Strategy before making any major system purchase.  Every component in the Enterprise Imaging Strategy needs to plug and play with all of the actors up and down the line.

 

In the world of medical imaging, the term “Enterprise Imaging” has become the latest buzzword. Exactly what is meant by this term depends on who is doing the talking. In my experience, there seems to be a considerable amount of confusion surrounding this subject, which inevitably leads to shortsightedness.

Over the last nine months, I have been asked by numerous healthcare organizations to help them develop their “Enterprise Imaging” Strategy.  Early on it occurred to me to ask the individual or organization to define their meaning of the term “Enterprise Imaging”, since defining the scope of a project is key to meeting expectations. Depending on the individual(s) participating in the initial conversation, the term “Enterprise Imaging” can mean any of the following:

1. Providing physicians and other caregivers access to the images being managed by their radiology and possibly cardiology PACS through their smart phones and tablets.
2. Consolidating the majority of the organization’s medical image data in a Vendor Neutral Archive (VNA).
3. Image-enabling the organization’s Electronic Medical Record (EMR) system.
4. Providing PACS-like functionality to imaging departments other than radiology and cardiology.
5. Managing and Displaying clinically relevant, digital photos and video clips taken with mobile devices (personal smart phones and tablets).
6. Exchanging medical images with affiliated (but outside) healthcare organizations, clinics, or physician groups.

In my opinion, focusing on any ONE of the above is shortsighted, as all of the above will eventually become the objective, assuming the ultimate goal of the healthcare organization is to provide all physicians and caregivers access to each patient’s complete longitudinal medical record and making this data displayable with a general-purpose viewer than can handle all of these diverse data objects.  The complete medical record would include the patient’s medical images (structured data), diagnostic reports, laboratory results, prescription details, and care summaries (unstructured data), and the multitude of health details collected during years of office visits such as age, weight, smoking status, etc. (discrete data).

The EMR currently manages the discrete data, but the unstructured and structured data is typically spread all over the enterprise in various independent silos that often do not interact with each other. To say that there exists an interfacing and data exchange issue here is a massive understatement.

Healthcare Leadership must come to terms with the breadth and complexity of this more comprehensive concept of “Enterprise Imaging”.  In order to convey this concept and eventually define the true End State of the Enterprise Imaging Strategy, I find it useful to look at the subject through several different lenses.

The first lens organizes the data by object type and location.  In the following summary list, we see how all of the data that should be in the patient’s longitudinal medical record is organized.

1. Unstructured Data
   • Scanned Documents
   • Care Summaries
   • Laboratory
   • Pharmacy
   • Voice Clips (WAV, AIFF, MP3, etc.)
   • Etc.
2. Structured Data
   • “Ologies” (image-based diagnostic procedures)
     1. Radiology
     2. Cardiology
     3. Ophthalmology
     4.  Pathology
        • Biopsy
        • Anatomical
     5. Otolaryngology
     6. Urology
     7. Others
   • “Oscopies” (examination of an organ, body cavity, or joint by viewing through an endoscope)
     1. Endoscopy
     2. Arthroscopy
     3. Laparoscopy
   • Surgery (digital video documentation of a procedure)
     1. Minimally Invasive
     2. General
     3. Robotic
   • Point-Of-Care Ultrasound (POCUS)
   • Mobile Imaging (capture of JPEG and MPEG digital images with a smart phone or tablet)
     1. Dermatology
     2. Wound Care
     3. Emergency
     4. Etc.
   • Outside Images (electronic image sharing between organizations)
3. Health Information Exchange (structured and unstructured data sharing between organizations)

The Unstructured data is best managed by an Enterprise Content Management (ECM) solution. Most EMR solutions are well equipped to mange the Discrete data associated with the patient, but their frequently limited indexing capabilities make them ill-equipped to efficiently manage either Unstructured or Structured data objects.  In most healthcare organizations, the Structured (image) data is currently being managed in department PACS or a Vendor Neutral Archive (VNA).  Another glance at the above list will confirm the observation that most healthcare organizations have barely scratched the surface when it comes to managing the Structured data associated with each patient (radiology and cardiology and frequently the endoscopy departments that have their local PACS). The questions that must be addressed by the Enterprise Imaging Strategy is how to acquire, manage and display all of the Unstructured data and the rest of the Structured data (image data) produced outside of those departments with a PACS.  The concept of a universal viewer must include more than just the ability to display the image data managed by the department PACS.

The first two categories in the above list cover data that is internal to the organization.  The third category covers the data associated with the patient that either must come from an outside affiliated organization, or must be transferred to an outside but affiliated organization. The interfacing and data exchange issues are even more critical in making this Health Information Exchange a reality.

The second lens organizes the data by object type and location.  In the following summary list, we see how all of the image data is divided based on how/where it is managed.

1. PACS – Department-based data management
   • Radiology
   • Cardiology
   • Endoscopy
   • Dentistry
   • Ophthalmology
2. Non-PACS – Modality-based data management (optional back-up server)
   • Endoscopy Camera systems
   • Otolaryngology Camera systems
   • Point-Of-Care Ultrasound system
   • Surgery Camera systems
3. Informal – Mobile device-based data capture /management
   • Dermatology
   • Wound Care
   • Emergency
   • Etc.

Once again, most organizations have barely scratched the surface regarding enterprise access to their image data.  Besides the big imaging department PACS (radiology, cardiology, and sometimes endoscopy), a large percentage of the patient’s image data is tucked away in the smaller imaging departments either on the individual imaging modalities/devices or on an optional back-up server in that department. Neither the modalities or the back-up server in these non-PACS environments are typically connected to another department’s PACS, a VNA, or a universal viewer tied to the EMR.  Consequently, all of these images are currently undiscoverable and inaccessible. The Enterprise Imaging Strategy must consider how these images will be included in the patient’s medical record and thus made available to the EMR viewer.

The Informal image category presents numerous challenges. First of all, in many healthcare organizations there is already a significant amount of “informal imaging” already in use.  Caregivers and physicians are using their personal mobile devices to take digital photos or video clips of wounds, rashes, numerous clinical conditions, and evidence of physical abuse. If these images remain on the personal device, or end up on “C” drives under the desk or on thumb drives, they are HIPAA violations waiting to happen. Transferring these mobile images to the EMR presents a different set of challenges such as how to assign unique identifiers to the images so finding them is easier and faster than searching through all of the images in the typical film roll of a camera app.  As previously stated, EMR solutions are not designed to effectively index either Unstructured or Structured data. The Enterprise Imaging Strategy must consider how these informal images will be captured, edited, appended with unique patient/study identifiers and a study description, where they will be managed, and how they will be displayed. If they are clinically relevant, they belong in the patient’s medical record.

The third lens also organizes the data by object type, but in this case we simply distinguish between DICOM and non-DICOM.

1. DICOM
2. Non-DICOM
   • PDF (document)
   • JPEG (still frame digital image)
   • MPEG (digital video)
   • WAV, AIFF, MP3, AU (audio files)

Most medical imaging devices in the larger imaging departments (radiology, cardiology, endoscopy, etc.) support the DICOM standard.  Consequently, most department PACS are designed to manage and display DICOM image data objects, whether the image data is stored in the PACS as a DICOM object or not. But most of the imaging devices in the other Ology and Oscopy departments that use imaging do not create DICOM image objects. Scopes and cameras produce JPEG and MPEG objects.  Voice clips and audio files can be one of several object formats.  A majority of the Unstructured data objects in the Enterprise Content Management system are PDF objects. The Enterprise Imaging Strategy must consider how to deal with both DICOM and non-DICOM data objects.

If the healthcare organization considers what truly belongs in the patient’s complete longitudinal medical record, then the term “Enterprise Imaging” becomes much more inclusive. When we view the contents through the three lenses I have presented in this document, we begin to appreciate the complexity and therefore the challenges in developing the more comprehensive strategic plan.